THE UPSIDE OF MEDICARE AUDITS TARA MONDOCK VP OF GOVERNMENT PROGRAMS & PAYER RELATIONS IVANS, INC.

Transcription

1 1 THE UPSIDE OF MEDICARE AUDITS TARA MONDOCK VP OF GOVERNMENT PROGRAMS & PAYER RELATIONS IVANS, INC. AHIA 31 st Annual Conference August 26-29, 2012 Philadelphia PA

2 Overview: Submitting Medical Documentation Electronically to Medicare Today s Agenda Presentation Objectives Background on Improper Payments Medical Documentation Process CMS esmd Program esmd Demo Medicare Review Contractor Perspective on esmd Current and future use cases for esmd Question & Answer 2 If you experience any technical difficulties during the webinar, please call

3 Acronyms Acronym ADMC ADR CERT CMS DRG esmd FFS HIH IT MAC Term Advanced Determination of Medicare Coverage Additional development or documentation request Comprehensive Error Rate Testing Centers for Medicare and Medicaid Services Diagnosis-related group Electronic Submission of Medical Documentation Fee for service Health Information Handler Information Technology Medicare Administrative Contractor 3

4 Acronyms Acronym NHIN ONC PERM RA TPL ZPIC Term National Health Information Network Office of National Coordinator Payment Error Rate Measurement Recovery Auditor Third Party Liability Zone Program Integrity Contractor 4

5 esmd Presentation Objective Increase provider awareness of Medicare Audits and the esmd Platform Highlight the esmd use cases and positive workflow implications Provide a forum for open discussion about the Medicare Audit and esmd initiatives 5

6 Background on Improper Payments Mdi Medicare has been consistently one of the top federal fd programs making improper payments CMS has deployed review contractors to conduct audits of Medicare payments to healthcare providers Medicare receives 4.8 M claims per day Claim review contractors issue over 1 million ADR requests each year Improper payments include: Incorrect payment amounts Incorrectly coded services Noncovered services (services that are not reasonable and necessary) Duplicate services CMS has created a new division solely focused on program integrity including improper payments and fraud and abuse 6

7 Audits are Big Business for the Government The CMS Office of Financial Management estimates that each year the Medicare FFS program issues more than $34.3 B in improper payments $1.03 B found in Medicare improper payments during Recovery Audit Demonstration Project in six states between % in overpayments 4% in underpayments The Recovery Audit Program is now permanent and nationwide 7

8 8 Different Types and Sizes of Hospitals Reported are Subject to RAC Review Percent Reporting RAC Activity vs. No RAC Activity by Type of Participating Hospital, through 1st Quarter 2012

9 Number of RAC Audits Performed is on the Rise 9 Number of Participating Hospitals Reporting RAC Number of Participating Hospitals Reporting RAC Activity by Region, through 1st Quarter 2012

10 10 Providers Continue to Report Dramatic Increases in RAC Denials and Medical Record Requests Reported Automated Denials, Complex Denials and Medical Records Requests by Participating Hospitals, through 1st Quarter 2012

11 Number of Medical Records Requested is Increasing 11

12 Providers are at Risk to Loose Millions of Dollars 12 $4.3 billion in Medicare payments were targeted $4.3 billion in Medicare payments were targeted for medical record requests through the 1st quarter of 2012

13 The average value of a medical record requested in a complex review 13 Average Value of a Medical Record Requested in a Complex Review Among Hospitals Reporting RAC Activity, through 1st Quarter 2012

14 The Hunt for Improper Payments is Ongoing and Expanding The Prepayment Review demo will allow Medicare Recovery Auditors to review claims before they are paid Preventing improper payments rather than the traditional pay and chase methods of looking for improper payments after they occur These reviews will focus on seven states with high populations of fraud- and error-prone providers FL, CA, MI, TX, NY, LA, IL And four states with high claims volumes of short inpatient hospital stays PA, OH, NC, MO 14

15 Providers Can Receive Audits From Many Types of Review Contractors Review Contractors include: 1. RA Recovery Auditor (Post-Payment and Pre-Payment NEW) 2. MAC Medicare Administrative Contractor (Pre-Payment) 3. CERT Comprehensive Error Rate Testing program Review Across All MAC Jurisdiction with focus on incorrect coding of claims, DRG upcoding or downcoding, and medical necessity 4. PERM Payment Error Rate Measurement program A claim is reviewed to determine if it was processed correctly, and the services were actually provided, medically necessary, coded correctly, and properly paid or denied. 5. ZPIC Zone Program Integrity Contractor Fraud and Abuse 15

16 Providers are Subject to an Audit by Recovery Auditors Every 45 Days All providers that bill Medicare and Medicaid are eligible to be audited by various Review Contractors Audits often require medical documentation to support claims Historically, i the documentation ti could only be mailed (either paper copies or on CD/DVD) The amount of paperwork submitted in 2010 by the average hospital was significant 150 medical record 225 pages of medical requests every audit documentation cycle (45 days) per request 33,750 total pages submitted on average 16

17 Today s Audit Request and Response Process Doc n Request Letter Review Contractor t Time and money that could be better spent delivering higher quality healthcare No record of receipt Paper Medical Record Printing and shipping costs Provider Administrative burdens 17

18 Providers Can Use Many Tools to Improve the Audit Experience Audit preparation Hire external consultants to do an audit and gap analysis Analyze past audit results to uncover areas for improvement in processes and documentation ti Organize a multi-functional team with an audit process champion to lead audit preparation and response Audit management Build or buy software tools to assist with the audit response process Document management Release of information Electronic submission 18

19 CMS Built the esmd Gateway To Address The Administrative Burdens CMS has built an Exchange Gateway to accept esmd transactions from providers. The CMS esmd gateway went live in September CMS uses the CONNECT brand of gateway Exchange 19

20 The Nationwide Health Information Network Set of standards, protocols, legal agreements, and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the public internet. Overseen by the ONC for Health IT Ensures that esmd transactions are SAFE and SECURE as they travel from point A to point B. 20

21 Providers Have Two Options for Accessing the esmd Gateway Build your own esmd Gateway Engage an HIH A Health Information Handler (HIH) is any company that handles health information on behalf of a provider 21

22 esmd How Does it Work? 22

23 HIH s are Simplifying the Audit Submission Process for Providers Medical record requests are sent to providers through the mail, responses are returned to Review Contractors electronically Providers upload files into the IVANS AuditDocs application, files then sent securely to Review Contractor using NHIN standards 23

24 esmd DEMO

25 Electronic Submission in 4 Easy Steps 1. Enter the audit information from the letter you received from the review contractor 2. Enter in claim information attached to the audit 3. Attach supporting medical documents to appropriate claims 4. Click submit you have successfully completed your electronic submission of medical documentation 25

26 AuditDocs UI Case/Claim ID Fields are entered from ADR letter If Case ID is found in the ADR Letter; this is not a required field For RAC Audits, the Audit ID will be noted; for MAC Audits, the Claim ID will generally also be the Case ID 26

27 Completion of Workflow: Creating a New Document Once the Metadata is entered, the user will proceed to the file upload part of the process click on New Document 27

28 Completion of Workflow: File Upload The user will Browse and Assign the documents 28

29 Audit Trail Provides A Return Receipt Confirming Documents Were Sent By Provider & Received by Contractor 29

30 Reporting Provides Tracking Capabilities The Search function allows the user to conveniently retrieve data on past audits, by applying various filters, and then clicking Search 30

31 From the Providers Perspective 31

32 Providers Using esmd Appreciate its Positive Impact on Workflow When we previously received an Additional Documentation Request (ADR) from CMS, we had to research, print and make copies of each document for that particular claim and then ship everything to the review contractor. Now, we just scan in our documents and upload everything, saving us hundreds of dollars in shipping and labor charges, and freeing up our staff to focus on more pressing healthcare responsibilities. Anthony Pryce, President of American Home Health Agency 32

33 From the Review Contractor t Perspective 33

34 The Review Contractor Perspective on esmd Reduces workloads for the provider cutting down on printing and shipping costs Quicker response time due to faster delivery Fewer denials due to missing filing deadlines Fewer appeals 34

35 The Submission of Medical Documentation is Only the Beginning Phase 1: Doc n Request Letter Live September, 2011 electronic Phase 2: electronic Live 2013 electronic 35

36 From the CMS Perspective 36

37 Current and Future Use Cases for esmd INBOUND Responses to Documentation Request Letters in PDF Appeal Requests in PDF Unsolicited Documentation in PDF (called paperwork or PWK ) Structured S d Orders, Progress Notes, ADMC Requests Structured esmd Phase 2 Registration here We are OUTBOUND Structured Outbound Documentation Requests Review Results Letters Demand Letters LOOKUP Request\Receive Documentation Status Request\Receive Claim Status Request\Receive Appeals Status Request\Receive Eligibility Info 37

38 CMS Resources Articles Medicare Learning Network (MLN) Special Edition Article SE1110, Medicare Pilot Project for Electronic Submission of Medical Documentation (esmd) pdf MLN Matters Article MM7254, Additional Fields for Additional Documentation Request (ADR) Letters p// / / / p df Web Explanation of esmd concepts and terms List of Medicare review contractors t accepting esmd transactions List of CMS-approved HIHs Frequently asked questions

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44 Alabama Quality Improvement Organization Alaska Quality Improvement Organization Arkansas Quality Improvement Organization Medicare Medicare Medicare Recovery Secondary Medicare Administrative Payer Part D Contractors Auditor Contractor Review Review (RAC) Central Contractor Contractors (MAC) PERM Unit (MSPRC) (MEDICs) (RADV) Medicare Part C Review Contractors CMS Private Network Content Transport Services Exchange ECM 44

45 For More Information CMS esmd Web site: Learn about IVANS IVANS AuditDocs 45

46 Thank You Questions From the Audience 46

47 Save the Date: August 25-28, nd Annual Conference Chicago, IL 47